Free Name of Person Filing - Arizona

Name of Person Filing: Your Address: Your City, State, Zip Code: Your Telephone Number: ATLAS Number (if applicable): Attorney Bar Number (if applicable): Representing Self (Without an Attorney) or

Petitioner or

Respondent

SUPERIOR COURT OF ARIZONA PINAL COUNTY
)
Name of Petitioner ) ) ) ) DO

RESPONSE TO CHILD SUPPORT INFORMATION FORM

Name of Respondent

STATEMENTS TO THE COURT, UNDER OATH: 1. INFORMATION ABOUT MY SPOUSE, the Petitioner:
Name: Address: Social security number: Job Title: Employer's Name: Employer's Address: Date of Birth:

2.

INFORMATION ABOUT ME, the Respondent:
Name: Address: Social security number: Job Title: Employer's Name: Employer's Address: Date of Birth:

3. 4.

INFORMATION ABOUT MARRIAGE:
Date of Marriage:

INFORMATION ABOUT YOUR CHILD(REN): The following child(ren) is/are under 18 and
were born to or adopted by my spouse and me during our marriage or paternity has been established. NAME SOCIAL SECURITY NUMBER DATE OF BIRTH

Currently Resides with: Current Address:

Mother

Father

© Superior Court of Arizona in Pinal County

DO5 Child
Use only most current

Support
January 15, 2003 version ALL RIGHTS RESERVED

Page 1 of 1

NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Currently Resides with: Current Address: NAME

Mother

Father

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Currently Resides with: Current Address: NAME

Mother

Father

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Currently Resides with: Current Address:

Mother

Father

5.

ACCESS
About how many days each week does the other parent see the children? About how much time each day days hours

6.

MEDICAL INSURANCE
Who provides medical insurance for the children? Mother or Father How much does that parent pay each month for the children's medical insurance? $ If you are not sure how much it costs to insure the children, state how much that parent pays and Number of people for how many people: $

7.

DAY CARE
Do the child(ren) require day care? Yes No If the child(ren) require day care, who pays it? Mother or Father How much does it cost each month on average over the entire year? $

8.

INFORMATION ABOUT SPOUSAL MAINTENANCE/SUPPORT
A. B. Does Mother regularly pay court-ordered spousal maintenance/support (alimony)? Yes No If so, how much each month? $ Does Father regularly pay court-ordered spousal maintenance/support? Yes No If so, how much each month? $

9.

INFORMATION ABOUT INCOME
A. What is Mother's gross (total) monthly income (before deductions and taxes)? $ DO5 Child
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© Superior Court of Arizona in Pinal County

Support
January 15, 2003 version ALL RIGHTS RESERVED

Page 2 of 2

B.

What is Father's gross (total) monthly income (before deductions and taxes)? $

10.

INFORMATION ABOUT OTHER CHILDREN.
A. B. C. Does Mother pay court-ordered child support for any other children? If so, how much each month? $ Does Father pay court-ordered child support for any other children? If so, how much each month? $ Yes Yes No No

Does Mother support any other natural or adopted children who also live with No Mother? Yes If so, how many and what are their names, ages and dates of birth?

D.



Does Father support any other natural or adopted children who also live with Father? Yes No If so, how many and what are their names, ages and dates of birth?

11.


OTHER CHILD SUPPORT ORDERS
Are there any other child support orders in effect for any of the children in described in #10 above? Yes No If so, list the name of the child affected, the name of the issuing court(s) and case number(s):

12.

PREGNANCY
Wife is not pregnant, or Wife is pregnant. The baby is due on (date), (and, check one box below) The Petitioner and Respondent are the parents of the child, or Petitioner is not the parent of the child, or Respondent is not the parent of the child

13.

SUMMARY OF WHAT I SAY ABOUT OUR CHILDREN THAT IS DIFFERENT FROM WHAT MY SPOUSE ASKED FOR IN THE CHILD SUPPORT INFORMATION FORM:

Address Information. It is very important for you (Petitioner and Respondent) to keep the court informed of your most current address. This means that if the address information on this form is incorrect or if you change address, you must contact the Clerk of the Court and give them your new or current address. Change of Address forms can be obtained at all of the courthouse locations. © Superior Court of Arizona in Pinal County DO5 Child Support
January 15, 2003 version ALL RIGHTS RESERVED Use only most current

Page 3 of 3

OATH AND VERIFICATION OF RESPONDENT STATE OF ARIZONA PINAL COUNTY ) )ss.

I, the Respondent, being duly sworn and under oath, state that I have read this Response. All the statements in the Response are true, correct and complete to the best of my knowledge and belief.

SIGNED: Respondent's Signature

SUBSCRIBED AND SWORN TO before me this

day of

, 20

,

My Commission Expires:

By Deputy Clerk/Notary Public

© Superior Court of Arizona in Pinal County

DO5 Child
Use only most current

Support
January 15, 2003 version ALL RIGHTS RESERVED

Page 4 of 4